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ADVANCE Perspective: Physical Therapy & Rehab Medicine

Study Finds Yoga as Effective as PT for Pain
by Katherine Bortz

As the most common cause of long-term disability, chronic pain has become one of the most widespread conditions in America. According to the U.S. Department of Health and Human Services, pain affects more Americans than diabetes, heart disease and cancer combined.

This year, the CDC released new guidelines for the treatment of chronic pain in March 2016 in response to the related rise in opioid addictions. Instead of doctors prescribing drugs like hydrocodone and morphine, they should first have their patients try a non-drug route. The CDC has recommended that physical therapy, weight loss, cognitive behavioral therapy and certain interventional procedures should be attempted first.

A new study has revealed that yoga for lower back pain, the most common cause of short-term and chronic pain in the country, is, according to director of integrative medicine at Boston Medical Center, Mass., Robert B. Saper, MD: “nonferior to physical therapy for a diverse group of low-income patients.” The 320 adults chosen for this study all had chronic back pain “with no obvious anatomic cause, such as spinal stenosis.” Pain levels were high for all participants, with an average pain scale rating reaching 7.

To see the effectiveness of various treatments, the sample group was split into three sections, with one practicing yoga, one receiving physical therapy and one receiving education on their condition. The results of the study were remarkable.

Saper claimed that 48% of those who practiced yoga were able to get some relief from the practice and achieve a clinical response. Physical therapy received a 37% reduction in pain, and education received a 23% reduction.

What does this mean for the future of physical therapists treating chronic lower back pain? Yoga appears to be a more effective, cheaper and reduces the amount of medication taken by patients as effectively as physical therapy.

Since yoga “is actually superior” to physical therapy and “quite a bit” superior to education, according to the researchers, should physical therapists start incorporating the practice of yoga into their work?

The study can be found here

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Is Yours the Next Practice of the Year?
by Jon Bassett
With temperatures outside our windows soaring well into record-breaking ranges -- 95 degrees and sticky here in the Northeast -- it's difficult to envision the frosty days of December. But we'd like to look ahead to our end-of-year cover story and wonder what private practice will be featured as our 2016 Practice of the Year.

Throughout the 15 years this esteemed contest has been in existence, we've taken you to solo-location specialty shops and multistate mega-chains. We've traveled from Elite Physical Therapy on the rocky New England coastline, to Physical Therapy Central on the Oklahoma plains, to Coury & Buehler Physical Therapy on the sunny shores of Orange County, California.

Along the way we've met transformative businesses that are leading the way in customer satisfaction, clinical expertise, staff development and promotion of the rehabilitation profession. Last year's winner -- Rehabilitation Associates of Central Virginia -- began operations in 1964 and continues to evolve to keep pace with current evidence, increased payor scrutiny and ever-shifting consumer preferences. Read more about this inspirational practice on our website.

Is your practice worthy of this prestigious honor? Take a break from building your business, and reflect on the accomplishments you've already achieved.

Submitting your practice for consideration is easy and there's no cost or obligation. Entries close Sept. 30, so don't delay -- visit www.advanceweb.com/pt and look for the Practice of the Year box.

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Olympic-Sized Injuries in Rio
by Katherine Bortz

When athletics become not only your profession but also a defining characteristic in your life, it’s hard to say when “enough is enough.” The Olympic Games have a history of showing fortitude and determination in its competitors, but there have been many examples of athletes with severe injuries pushing past their own limits to reach the top of the podium.

Kerri Strug is undoubtedly one of the most notable injured athletes of the past. The gymnast with two torn ligaments in her ankle was able to score an impressive 9.712 on a difficult vault. Once she landed, she immediately took all weight off of her left foot and proceeded to make her way off the mat with the help of others. With this vault, she helped secure gold for the 1996 women’s gymnastics team, but had to be carried to the awards ceremony by Coach Bela Karolyi.

This year’s Olympic Games in Rio proved to be no different than the ones in year’s past. Several athletes worked through severe injuries while others made the call to drop out. These athletes were noticeably affected by their injuries:

  • Armenian weightlifter Andranik Karapetyan   hyperextension of the elbow while lifting
  • French gymnast Samir Aït Saïd  – double break in leg
  • Cyclists Richie Porte (Australia) and Vincenzo Nibali (Italy)  various injuries after crash, including broken collar bones
  • Cyclist Annemiek van Vleuten (Netherlands) three broken vertebrae and a major concussion after crash
  • Gymnast Elissa Downie (Great Britain) – fell directly on head and neck after tumbling pass* 

*continued to compete after injury

As a physical therapist, when do you think “enough is enough”? Are there times where you think that the athlete should have to put their health second? Let us know what you think in the comments.

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Balenger Inspires at APTA NEXT 2016
by Katherine Bortz

The APTA NEXT 2016 conference kicked off on June 8 with an inspiring story of how physical therapy can truly transform lives.

Nick Balenger was vacationing in Hawaii when he dove into the ocean. Instead of plummeting into deep water, he hit the sandbar and suffered a severe spinal cord injury, dislocating the C4 and C5 vertebrae. Just prior to the injury, Balenger helped lead the Lake Braddock Secondary School baseball team to victory in the Virginia state baseball championships as pitcher. After the injury, he was told he would never walk again.

"For about 3 weeks, I was in the ICU of the Maui Memorial Hospital, unable to move anything below my neck other than my biceps. So about all I could do was punch myself in the face," Balenger said.

Everything changed the day that he realized he was able to make very small movements with his leg.

"I knew I would take that fraction of an inch, turn it into 2 inches, 6 inches and before long a whole step," he said. By his high school graduation in 2013, only a year later, he was able to walk across the stage to receive his diploma with the help of a crutch.

During his speech, he thanked his physical therapists for where he is today and for not giving up on him.

Have you dealt with remarkable cases like Nick's? Has a physical therapist personally changed your life for the better? Comment below!

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Dormant Butt Syndrome
by Dillon Stickle

There are many reasons a person might be experiencing chronic pain - improper posture, poor work ergonomics and repetitive stress, and recurring injuries to name a few. But a less obvious reason is making its way into the spotlight: Dormant Butt Syndrome (DBS). In an article from the Washington Times, Dr. Chris Kolba, a physical therapist at Ohio State University's Wexner Medical Center, claims that DBS, a condition in which weakened glute muscles do not perform the way they should, may be the cause of chronic pain in anyone from professional athletes to office workers.

In the article, Kolba stresses that "The rear end should act as support for the entire body and as a shock absorber for stress during exercise. But if it's too weak, other parts of the body take up the slack and often results in injury." He said that the main causes are sleeping in the fetal position and sitting for long periods every day; after all, sitting is the new smoking.

So, what do we do about our weakened, inefficient gluteus Maximus? Kolba has two suggestions: keeping our hips mobile with stretching and flexibility exercises, as well as strengthening our glutes with strength training exercises like squats or lunges.

PTS, have you had any patients with chronic pain who might have DBS? What treatments would you recommend? Do you think DBS might be the underlying cause of chronic pain in millions of Americans? Do you disagree with Kolba's claim? Let us know in the comments!

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CMS Scrutinizes Joint Replacement Outcomes
by Jon Bassett
Some would say it was a matter of inevitability. Others will hail its arrival as a much-needed shift away from pay-per-procedure and toward pay-for-quality.

On April 1, 2016, CMS began the testing phase of its Comprehensive Care for Joint Replacement (CJR) model, a new payment structure for episodes of care related to total knee and total hip replacements under Medicare.

According to CMS, Medicare beneficiaries received more than 400,000 knee and hip replacement surgeries in 2014. While these procedures enjoy massive appeal because of their ability to improve overall quality of life, complications and costs vary significantly.

The CJR testing phase is planned to last five years and will be implemented in 67 metropolitan statistical areas, including almost 800 hospitals.

One such region is the New York Metropolitan area, which includes Northwell Health, consisting of 21 hospitals and nearly 450 outpatient practices. Fourteen of its hospitals will participate in the CJR pilot project, becoming responsible for both the cost and overall quality of care delivered to Medicare patients for 90 days after their procedures.

"The discharge from the hospital is not the end of the medical journey for the patient, but marks the beginning of the next phase of recovery," remarked Zenobia Brown, MD, MPH, medical director at Northwell Health Solutions.

CMS is billing the CJR pilot project as a departure from the traditional "fee-for-service" model of care, in which providers are paid whenever they treat a patient. The bundled payment system holds hospitals accountable for all costs incurred during the entire episode of a patient's care -- from admission, to surgery, inpatient hospital stay, rehabilitation, and other care delivered after the patient leaves the hospital. 

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Study Shows Benefits of PT for Obese COPD Patients
by Katherine Bortz

A new study has surfaced displaying the benefits of physical therapy for obese patients hospitalized with Chronic Obstructive Pulmonary Disease (COPD).

Researchers at the University of Granada and Virgen de las Nieves Hospital, both located in Spain, have seen results that suggest less hospitalization for those suffering with the disease. Their results show that a short-term physical therapy regimen leads to a better quality of life for the patient and is more cost effective for the hospital. Forty-nine patients were selected to receive multimodal therapeutic care. The regimen was carried through for seven to 10 days. The project was funded by the Health and Progress Foundation, Boeghringer Inghelheim and Oximesa.

The exercises mostly focused on the lower extremities, included work with elastic bands, pedaling and activities where patients were seated. Patients also were given routines where balancing on one foot was required. The researchers concluded that there were beneficial effects of physical functioning in hospitalized obese patients with acute exacerbation COPD.

This research is published in “COPD: Journal of Chronic Obstructive Pulmonary Disease.”

COPD is a chronic inflammatory lung disease where airflow from the lungs is obstructed. According to Mayo Clinic, symptoms include: breathing difficulty, cough, sputum production and wheezing. In many cases, COPD is developed by smokers or those who have had long-term exposure to irritating gases or particulate matter.

How do you think that physical therapists can help improve the lives of those hospitalized with chronic conditions, including COPD?

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New Guideline Promotes PT for Chronic Pain
by Katherine Bortz
Chronic pain is becoming a worsening problem in America, with 14.6% of the population living with symptoms daily. Currently, the first line of defense against the condition is through the prescription of opioids such as transdermal fentanyl, and extended-release versions of opioids such as oxycodone, oxymorphone, hydrocodone and morphine. While they do alleviate symptoms of the condition, they also have an increased chance for misuse or addiction. Many are beginning to wonder if this is really the best way to go about treating patients.

The CDC recently published its guideline for prescribing opioids and urged healthcare professionals to weigh the benefits of certain therapies with the risks. In this guideline, a conclusion was reached that non-opioid and non-drug options like physical therapy, weight loss for knee osteoarthritis, psychological therapies such as cognitive behavioral therapy (CBT) and certain interventional procedures should be attempted first.

This guideline is partially in response to the rising epidemic of opioid addiction and overdose, but it is also in response to the increasing rate of patients who see positive results from these non-drug treatments: "There is high-quality evidence that exercise therapy (a prominent modality in physical therapy) for hip or knee osteoarthritis reduces pain and improves function immediately after treatment and that the improvements are sustained for at least 2-6 months." Other forms of physical and exercise therapies suggested include aerobic, aquatic, and/or resistance exercises for patients with osteoarthritis of the knee or hip.

The CDC also reports that more compassionate and appropriate care should be offered by healthcare professionals to people suffering from chronic pain, as many live with clinical, psychological and social consequences. These include issues with work productivity, restrictions in complex activities and stigma.

What do you think about the CDC's stance, and what do you think are the best practices for treating those with chronic pain? Let us know in the comments.

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Future of the PTA Profession
by Dillon Stickle

ANAHEIM, CA -- Today at CSM, in a lecture titled "Transforming the Role of the PTA to Meet the Vision of the Physical Therapy Profession," speakers Jennifer Jewell, PT, DPT, Beverly Labosky, PTA, BA, Pamela Pologruto, PT, DPT, and Gina Tarud, PT, DPT, took a look at how the role of the PTA should meet the APTA's new vision: transforming society by optimizing movement to improve the human experience.

The speakers noted that the profession should anticipate the future knowledge requirements of the PTA. They looked at the historical perspective of the occupation, including the evolution of the liensure exam and the change in requirements of the PTA.

They looked at the current role of the PTA, specifically on supervision, continuing education, and the overall scope of the PT practice.

On supervision, a surprising 68% of states had PTAs under general supervision -- the lowest level of supervision offered to the PTA -- while only 10% had direct on-site supervision.

On continuing education, statistics showed that 43 states required at least 8 hours of CEUs. They presented a number of advancement opportunities to PTA graduates, but an overwhelming number of PTAs did not know of the opportunities that were out there.

The speakers then took a look at PT/PTA perspectives and found that there were specific challenges facing the field:

- Underutilization of the PTA (including the lack of education for the PT on the role of the PTA)

- Insurance company regulations

- State practice act regulations

- Delegation

- Lack of opportunities

- Productivity standards

Finally, they took a look at the next step for the PTA profession. For example, they played with the idea of tiered degree programs, like that of the nursing programs (RN, BSN, MSN, etc.) and how that could be implemented. Another would be to advance continuing education and credentialing opportunities for the PTA.

The lecture ended with a fitting quote from Walt Disney: "Around here, we don't look backwards for very long; we keep moving forward, opening new doors and doing new things because we're curious... and curiosity keeps leading us down new paths."

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"Unflattening" Higher Education
by Dillon Stickle

ANAHEIM, CA -- Diane Jette, PT, DPT, DSc, FAPTA presented the thought-provoking lecture, "Unflattening," tonight for the Pauline Cerasoli Lecture. The title was named after the book Unflattening by Nick Souzanis, a novel that presents a serious inquiry into the ways humans construct knowledge. This was directly related to Jette's thoughts and ideas on higher education. She showed a video from Cosmos that showed the world, and all who inhabit it, as flat. But an apple, a three-dimensional object, came and defied the normal way of living. Jette said, "I am the apple. I am going to be the third dimension of higher education."

Jette then asked everyone to break through the two-dimensional idea of their profession and challenge the status quo of higher education.

She went on to discuss the reasons higher education is on a downhill slope; politics as usual, institutions grappling with lowering costs but saving revenue, static data which produces ill-equipped graduates, lack of student diversity, and much more.

Jette then asked a provocative question: How long will it take for increases to the price of our programs to diminish the value of entering the physical therapy profession?

At the end of her lecture, Jette asked the audience to consider these 6 suppositions:

1. It is our responsibility to address the need for diversity in the healthcare workforce and consequentially improve access to healthcare.

2. We must prepare graduates to work in a complex healthcare system in which uncertainty is the norm.

3. We need curricula reform.

4. Costs of the programs and the level of student loan debt are unsustainable.

5. Professionals have to become more efficient.

6. Work together -- accelerate learning through networked connections.

We look forward to covering more challenging lectures on the state of the physical therapy profession here at #APTACSM!

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Words Mean Things
by Dillon Stickle

ANAHEIM, CA -- Language, both verbal and non-verbal, are important tools in the therapist-client relationship. In a lecture called "Words Mean Things: How Communication Impacts Clinical Results" given by Kevin Lulofs-MacPherson, PT, DPT, OCS, Larry Benz, PT, DPT, OCS, MBA, and Tim Flynn, PT, PhD, we learned the value of language and how it can affect the outcomes of a therapist's client.

The speakers went through things like verbal and non-verbal layers of communication. We learned that patient satisfacion is tied to social talk, direct eye contact, body language, physical contact, close interpersonal distance, less time on a chart, and not frowning. They said that distancing behaviors in the therapist leads to poor functional outcomes for the patient.

An interesting take was that of anxiety in the patient. If a patient is given an angry expression, it results in an avoidance tendency; however, studies show that if the patient is given an overly happy expression, the outcome is often the same as when they're given an angry expression. The speakers questioned whether PTs need to start "toning down" their approach to communicating with patients.

One of the speakers went over "thinking traps," one being the use of abstract words. The more abstract a word, the heavier the load on your brain. Another "trap" was the idea that PTs are empathetic by nature. They said that PTs actually need to learn and condition their empathy -- "it's like a muscle." It was suggested that if you do not like the word "empathy" then to think of it as curiosity.

In this session, PTs were challenged to reconsider their role in the "therapeutic alliance," which is the relationship between the healthcare professional and the client. Should they continue looking at an iPad while their client looks around, not really paying attention to the session? Or should the therapist offer the patient a look at the iPad as well, so that there is a "shared object of attention"? I think after today, most PTs would consider the latter to result in the best patient outcomes.

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Empathy in the Curriculum
by Dillon Stickle

ANAHEIM, CA -- As most of you know, the APTA Combined Sections Meeting (CSM) is underway, and ADVANCE is excited to be here to cover the happenings of the nation's largest conference for physical therapy. According to the CSM website, this year's conference has brought over 10,000 professionals from all around the country to join in learning and celebrating the physical therapy profession, and to hear from veteran PTs speaking on various topics.

The first notable session was the Linda Crane Memorial Lecture, named after one of the first PTs to be certified in a specialty by the APTA. The speaker was Julie Ann Star, PT, DPT, CCS, clinical associate professor at Boston University and physical therapist at Beth Israel Deaconess Medial Center in Boston, MA. The title of her lecture was "The Science of Healing. The Art of Caring. #heartofthematter."

Star told stories of her days as a PT, and as a healthcare professional in general. She told the story of the Boston Marathon bombing, and how when push came to shove, every single healthcare professional there that day stepped up to the plate. Star asked a question to the audience; a thought-provoking question: Which way will you run? She said that the responsibility of the professional is to run toward the danger; after all, the core idea of healthcare is to help people who are sick or hurt.

Star followed these stories with an idea that maybe the curriculum of PT schools didn't involve enough learning of empathy, compassion, and communication. This was the "art" of physical therapy. She shared a shocking study that showed in the last 10 years, empathy in DPT students has dropped dramatically. She pondered: "If the art of PT is to ensure the highest standard of excellence, then we need to be intentional about it. Are we teaching this in our curriculum?"

At the end of the lecture, Star told a memory of the week after the bombing, when her friend asked, "Isn't the younger brother alive and being treated at your hospital?" After Star replied, "yes," her friend asked, "Well, you're not going to help take care of him, are you?"

 Star looked to the audience and challenged: "would you?"

 We will be covering a lot more at #APTACSM in the next couple days and are excited to see what else the conference has in store. Check in with us for more updates, and be sure to follow us on Facebook (Advance for Physical Therapy and Rehab Medicine) and Twitter (@AdvanceforPT)!

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PT and OT Stand Out in 2016 ‘Best Jobs' Ranking
by Brian Ferrie

Every year, professionals, students and prospective students across the country eagerly await "The 100 Best Jobs" ranking published by U.S. News & World Report. The just-released 2016 list offers great reason for physical and occupational therapy professionals to feel proud, and for students to feel optimistic about pursuing careers in these fields. 

Among the 100 Best Jobs overall, physical therapist ranked a very impressive #14, while physical therapist assistant (#40) and physical therapist aide (#52) also represented well. The occupational therapy field enjoyed significant recognition too, with occupational therapist ranking #23, occupational therapy assistant #25, and occupational therapy aide #59. In the "Best Health Care Jobs" ranking specifically, the numbers were even more eye-catching, with physical therapist ranking #12 and occupational therapist #17.

U.S. News states, "Good jobs are those that pay well, challenge us, are a good match for our talents and skills, aren't too stressful, offer room to advance and provide a satisfying work-life balance. Even though there is no one best job that suits each of us, the 100 Best Jobs of 2016 are ranked according to their ability to offer this mix of qualities. Also, the best careers are ones that are hiring."

According to U.S. News, the U.S. Bureau of Labor Statistics projects a physical therapist job growth rate of 34 percent by 2024, with an occupational therapist growth rate of 27 percent over the same time period.

What are your thoughts about the rankings and their reflection on these rehabilitation professions? Do you believe that physical and occupational therapy offer some of the best careers in the country?

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Therapy for Parkinson's
by Dillon Stickle
The Journal of the American Medical Association (JAMA) Neurology released a study on Tuesday which suggested that the current standard of care for early-stage Parkinson's patients may be a waste of time and money. The study said that both PT and OT offer "no improvement of quality of life" and that there were no "short or medium-term benefits."

A recent article on ADVANCE for Physical Therapy and Rehab Medicine claimed that, "Patients today are far more educated on the disease, have lots of questions, and know that physical therapy combined with prescribed exercises will impact their quality of life moving forward. Potentially, it could even slow the progression of the disease."

We shared the study with our Facebook fans via a Yahoo News article, and there seemed to be a united consensus: the study was misleading or misrepresentative of the role PT plays in the treatment of a patient with Parkinson's disease.

Here are some things PTs had to say:

"Treating injuries is not the main focus of any plan of care from a skilled PT that is treating someone with PD."

"That seems at odds with the multiple studies that have clearly shown how exercise and therapy benefit Parkinson's patients short- and long-term."

"If there was no progress or benefits for PD patients in this study, than the PTs may need a review of how to write functional goals."

"It depends on what the PT focuses on. Doing only strengthening exercises won't help. Focusing on balance, movement strategies, etc. does help. But, these have to be incorporated into daily life by the patient and family/caregiver."

Some fans pointed out the fact that balance exercises and range of motion were not part of the study, which many PTs consider their role to improve in a patient with Parkinson's. Some even argued the study was skewed because of biased healthcare providers.

What are your thoughts on the role of PT in cases of patients with Parkinson's? Let us know in the comments.

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Can Helmetless Drills Decrease Football Head Impacts?
by Brian Ferrie

The National Athletic Trainers' Association (NATA), Dallas, issued an interesting press release Dec. 18 related to the hot-button issue of head impacts in football. The release stated:

"Head impacts in football players are directly associated with brain and spine injury and have been suggested to be associated with chronic injuries, making this a topic of continued national concern. To reduce the risk of head-impact injury, researchers and others have sought ways to improve helmet technology, reduce contact during practices, and alter game rules."

A new study, "Early Results of a Helmetless-Tackling Intervention to Decrease Head Impacts in Football Players," published in the Journal of Athletic Training investigated the effectiveness of helmetless tackling to reduce head-impact exposure in an NCAA Division I football program.

"Given proper training, education and instruction, college football players can safely perform supervised tackling and blocking drills in practice without helmets," said Erik E. Swartz, PhD, ATC, FNATA, lead author of the study and professor and chair, Department of Kinesiology, University of New Hampshire. "This intervention also eliminates a false sense of security a player may feel when wearing a helmet. Younger players with less experience may require modifications to this intervention to realize a positive effect. While more research is needed, our results do show a reduction in head impacts during our one season of testing."

The results stem from the first year of a two-year study focusing on 50 NCAA Division I football players at the University of New Hampshire who were assigned to an intervention or control group. The intervention group participated in 5-minute tackling drills without their helmets and shoulder pads. Drills occurred twice per week during preseason practices and once per week throughout the competitive season. Meanwhile, the control group performed noncontact football skills with no change to their routine. All athletes were provided head-impact patch sensors worn on the skin and new helmets. At the end of the season, the intervention group experienced a 28-percent reduction in head impacts during practices and games than the control group.

"These findings elucidate the risk-compensation phenomenon and may help explain the behavior of spearing and the rise in catastrophic neck and head injuries that followed," the study authors noted. "A football helmet is designed to protect players from traumatic head injury, but also enables them to initiate and sustain impacts because of the protection it affords. While improving protective equipment in and of itself will not resolve the risk of concussion and spine injury in football, the solution may be found in behavior modification."

What are your thoughts about this study and the merits of helmetless drills to help reduce head impacts in football?

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